Tuesday, December 20, 2016

Salaries for female physicians average some $19,879—eight percent—lower than male physicians. At academic hospitals, male physicians receive more research funding and are more than twice as likely as female physicians to rise to the rank of full professor.

These disparities have historically been attributed to the effects of disproportionate domestic responsibilities—including maternity leave and subsequent part-time schedules. As physicians Rita Redberg and Anna Parks note, this can be perceived to "undermine the quality of female physicians' work and explain male physicians' higher salaries."

But no. Female physicians actually tend to provide higher-quality medical care than males, according to research released today. If male physicians were as adept as females, some 32,000 fewer Americans would die every year—among Medicare patients alone.

Friday, December 16, 2016

Not all hospitals are created equal, and the differences in quality can be a matter of life or death.

In the first comprehensive study comparing how well individual hospitals treated a variety of medical conditions, researchers found that patients at the worst American hospitals were three times more likely to die and 13 times more likely to have medical complications than if they visited one of the best hospitals.

Tuesday, December 13, 2016

Billions of dollars are spent every year on medications that reduce the risk of heart disease — the No. 1 killer in the United States.

But some people feel powerless to prevent it: Many of the risk factors seem baked into the cake at birth. Genetic factors can have a huge impact on people's chances of dying of heart disease, and it has long been thought that those factors are almost always outside of one's control.

Sunday, November 27, 2016

The Center for Innovative Collaboration in Medicine and Law is a joint effort of the FSU College of Medicine and FSU College of Law. The mission is to identify and facilitate (through education, the conduct and dissemination of scholarship, and performance of service activities) opportunities for members of the medical and legal professions, working together and with others, to foster improvements in the quality of life enjoyed by individuals and to promote public health in Florida, the United States, and globally.

Saturday, November 19, 2016

The number of doctors who each prescribe millions of dollars of medications annually in Medicare's drug program has soared, driven by expensive hepatitis C treatments and rising drug prices overall, federal data obtained by ProPublica show.

The number of providers who topped the $5 million mark for prescriptions increased more than tenfold, from 41 in 2011 to 514 in 2015. The number of prescribers — mostly physicians but also nurse practitioners — exceeding $10 million in drug costs jumped from two to 70 over the same time period, according to the data.

Most of the doctors atop the spending list prescribed Harvoni or Sovaldi, relatively new drugs that cure hepatitis C. Other providers on the list prescribed pricey drugs to treat cancer, multiple sclerosis and rheumatoid arthritis.

Thursday, November 17, 2016

A new report from Harvard Law School proposes drastic changes in the way health care is administered in the NFL, urging the nation's most popular sports league to upend its system of medicine and untangle the loyalties of the doctors and trainers charged with treating players.

Asserting that the long-standing current structure has inherent conflicts of interest, the 493-page report outlines a new system in which a team's medical staff is devoted solely to players' interests and no longer reports to team management or coaches.

"The intersection of club doctors' dual obligations creates significant legal and ethical quandaries that can threaten player health," the report states.

The two-year study bills itself as the first of its kind in "examining the complicated and often-paradoxical universe of stakeholders that may influence NFL player health." The NFL strongly took issue with the methodology and conclusions drawn by the Harvard researchers.

On Nov. 1, Jeffrey Miller, the NFL's executive vice president of health and safety, sent the researchers a 33-page response in which he rejected any suggestion that NFL doctors have conflicts of interest and called the proposed change "untenable and impractical." He said researchers have called for "several unrealistic recommendations that would not improve player care."

The report "cites no evidence that a conflict of interest actually exists," Miller wrote. ". . . The Report identified no incident in which team physicians were alleged to have ignored the health status of players, failed to adhere to patient confidentiality consent procedures, or made recommendations to clubs that were contrary to the health of players."

Sunday, November 13, 2016

Many people have to wait too long to see a doctor. And it could get worse. If, as many people believe, we have a shortage of doctors in the United States, then it follows that we can fix this only by training and hiring more physicians.

As with almost everything in our health care system, though, it's complicated. Some people think there's no shortage at all — just a poor distribution of the doctors we have.

The main argument for a physician shortage is that we aren't adding enough new doctors to keep up with changing demographics. The Association of American Medical Colleges has projected that by 2025 there will be a shortfall of between 46,100 and 90,400 doctors. In primary care, it projects a shortfall of between 12,500 and 31,100 doctors.

The baby boomers are getting older and sicker, and they have more complex conditions than they did when they were younger, including arthritis, high blood pressure, pulmonary disease, diabetes and cancer. The Affordable Care Act is expected to accelerate the need for additional medical care. Increased insurance coverage increases demand, and Obamacare alone is projected to require about 16,000 to 17,000 more physicians than would have been required without it.

Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).

The United States had 2.56 doctors per 1,000 people, which is more than Canada (2.46), Poland (2.24), South Korea and Mexico (both 2.17). But we were way behind countries like Austria (4.99), Norway (4.31), Sweden (4.12), Germany and Switzerland (both 4.04).

Based on these metrics, it would seem that we need more physicians. It would also seem that we're not training them. When it comes to medical graduates, the United States ranks 30th of 35 countries.

But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn't really need to invest more in new physicians.

Saturday, November 12, 2016

For older people who fracture a hip, the prognosis is grim: a third or more die within a year and only about 1 in 5 return to their pre-injury level of function.

A new approach to care could mean it doesn't have to be that way.

More hospitals are putting hip fracture patients on a fast track from the emergency room to the operating room, repairing the fracture in as little as six hours after diagnosis. The approach appears to produce significantly better outcomes for patients than the conventional practice of waiting up to three days before operating on the fracture. It can also reduce the costs of complications and longer hospital stays.

Saturday, October 29, 2016

Erin Olivera waited weeks for doctors to tell her why her youngest son was paralyzed.

Ten-month-old Lucian had started crawling oddly — his left leg dragging behind his right — and soon was unable to lift his head, following Erin only with his eyes.

She took him to a hospital in Los Angeles, but doctors there didn't know how to treat what they saw.

Lucian's legs felt soft as jelly and he couldn't move them. His breathing became rapid. The left side of his smile drooped as his muscles weakened.

Physicians ran test after test, and Erin began spending her nights on a hospital room couch. After Lucian fell asleep, during her only minutes alone between working and visiting her three other kids, she cried.

A terrifying reality was taking hold: Doctors wouldn't be able to give her a diagnosis for her paralyzed child.

"How can I make a decision for him when I don't even know what's wrong?" she said. "What can I do to help him?"

So one morning in July of 2012, Erin lifted Lucian out of his hospital bed, his body limp and heavy. She rested his cheek on her shoulder, the way he liked to be held since he'd become weak.

Erin returned home to Ventura County with a child she thought might never learn to walk.

In the years since, hundreds of children across the country have shown up at hospitals unable to move their arms or legs. Dozens of kids have become paralyzed in the past few months alone.

They suffer from a mysterious illness that continues to alarm and puzzle scientists. This kind of sudden and devastating paralysis hasn't been widespread since the days of polio. Lucian, one of the disease's earliest victims, set off a hunt among doctors to discover its cause.

Wednesday, October 26, 2016

Late Friday afternoon on Dec. 4, 2014, Stephen Schroeder was waiting to board his packed flight from Philadelphia to Las Vegas for a much anticipated long weekend with his son when his cellphone rang. On the line was an unexpected caller: his doctor, reporting test results sooner than Schroeder had expected.

Listening intently, Schroeder was flooded with disbelief as he struggled to comprehend what he was hearing. Using the lip of a trash can as a writing surface, he scribbled notes on the back of his boarding pass, making the doctor spell out each unfamiliar word. Then he sent a terse text to his wife, who was at their home in the Philadelphia suburbs, and got on the plane.

Onboard, Schroeder, then 55, fired up the balky in-flight Internet, desperate for information.

What he read over the next five hours left him alternately terrified, stunned and then, as denial took over, skeptical. "I kept thinking this must be some kind of really stupid mistake," he recalled. "The diagnosis had to be wrong."

Spokane sales manager Steve Schroeder, along with his doctors, thought he had a bad case of jock itch for more than a year. (Courtesy of Steve Schroeder)
Schroeder would discover that the pesky rash he and his doctors had dismissed as inconsequential would take over — and threaten — his life.

The experience would provide a crash course in the importance of finding experts who could provide appropriate treatment, in the necessity of learning as much as possible about a disease, and in the loneliness of coping with a diagnosis so rare it lacks a support group.

If the opiate crisis has taught us anything, it's that addiction affects everyone. An unprecedented surge in fentanyl-implicated death—across all incomes and backgrounds, obviously—has sparked public health emergencies across the US and Canada. With each fentanyl overdose reported, we're seeing ignorant assumptions about who uses drugs and why finally put to rest.

But there was a time when fentanyl was almost exclusively used by a very small group, and it had nothing to do with Margaret Wente's idea of a "typical drug addict" or poverty or organized crime. What the general public is oblivious to—but the medical community knows—is how fentanyl addiction took its roots in anesthesiology before it made its way into the mainstream.

Dr. Ethan Bryson, associate professor in the anesthesia and psychiatry departments at the Icahn School of Medicine at Mount Sinai, New York, believes it was anesthesiologists who, familiar with fentanyl's pharmacology and abuse potential, first began misusing the opioid.

"If you look at the history of morphine, cocaine, and heroin, these were all drugs which were initially developed for legitimate medical purposes, but subsequently became recreational pharmaceuticals," Bryson told VICE. "They were all experimented on with people with that access. That's well documented in history."

Saturday, October 8, 2016

The newest iteration of the Global Burden of Disease study, which tracks the prevalence of deaths and diseases worldwide, contains some good news: On average people are living about a decade longer than they were in 1980. But there's a catch: Health hasn't improved as fast as life expectancy overall, which means that for many, those long, final years are spent hobbled by illness and disability.

The nature of our old-age ailments has changed in recent years. The study, published this week in The Lancet and conducted by the Institute for Health Metrics and Evaluation at the University of Washington, uses a metric called "Disability Adjusted Life Years." DALYs, as they're abbreviated, combine the number of years of life a person loses if they die prematurely with the amount of time they spend living with a disability. Think of it as time you didn't spend living your #bestlife—because you were sick or dead.

In rich countries, the number one cause of these DALYs is not surprising: ischemic heart disease, which is associated with well-known Western issues like high cholesterol and obesity. But the number two condition is a little strange: plain, old-fashioned, ever-present, low back and neck pain.

Even when you include poor and middle-income countries, low back and neck pain went from ranking 12th as a cause of DALYs globally in 1990 to ranking fourth in 2015, the most recent year. In most countries, it was the leading cause of disability. DALYs from low back and neck pain increased by more than 17 percent from 2005.

The things that make us low-level miserable are now more likely to be simple aches and pains, rather than frightening, communicable diseases like diarrhea. That's encouraging, but it's still a little sad. People all over the world increasingly live long, great lives, only to spend their golden years slathered in IcyHot.

Friday, October 7, 2016

We know that Americans are increasingly sorting themselves by political affiliation into friendships, even into neighborhoods. Something similar seems to be happening with doctors and their various specialties.

New data show that, in certain medical fields, large majorities of physicians tend to share the political leanings of their colleagues, and a study suggests ideology could affect some treatment recommendations. In surgery, anesthesiology and urology, for example, around two-thirds of doctors who have registered a political affiliation are Republicans. In infectious disease medicine, psychiatry and pediatrics, more than two-thirds are Democrats.

The conclusions are drawn from data compiled by researchers at Yale. They joined two large public data sets, one listing every doctor in the United States and another containing the party registration of every voter in 29 states.

Eitan Hersh, an assistant professor of political science, and Dr. Matthew Goldenberg, an assistant professor of psychiatry (guess his party!), shared their data with The Upshot. Using their numbers, we found that more than half of all doctors with party registration identify as Democrats. But the partisanship of physicians is not evenly distributed throughout the fields of medical practice.

Thursday, October 6, 2016

After his 34-year-old wife suffered a devastating asthmaattack and later died, the Boston writer Peter DeMarco wrote the following letter to the intensive care unit staff of CHA Cambridge Hospital who cared for her and helped him cope.

As I begin to tell my friends and family about the seven days you treated my wife, Laura Levis, in what turned out to be the last days of her young life, they stop me at about the 15th name that I recall. The list includes the doctors, nurses, respiratory specialists, social workers, even cleaning staff members who cared for her.

"How do you remember any of their names?" they ask.

How could I not, I respond.

Every single one of you treated Laura with such professionalism, and kindness, and dignity as she lay unconscious. When she needed shots, you apologized that it was going to hurt a little, whether or not she could hear. When you listened to her heart and lungs through your stethoscopes, and her gown began to slip, you pulled it up to respectfully cover her. You spread a blanket, not only when her body temperature needed regulating, but also when the room was just a little cold, and you thought she'd sleep more comfortably that way.

You cared so greatly for her parents, helping them climb into the room's awkward recliner, fetching them fresh water almost by the hour, and by answering every one of their medical questions with incredible patience. My father-in-law, a doctor himself as you learned, felt he was involved in her care. I can't tell you how important that was to him.

Then, there was how you treated me. How would I have found the strength to have made it through that week without you?

Wednesday, October 5, 2016

Max Ritvo, an accomplished poet who spent much of his life under the cloud of cancer while gaining wide attention writing and speaking about it, died of the disease on Tuesday at his home in Los Angeles. He was 25.

His mother, Dr. Ariella Ritvo-Slifka, confirmed his death.

Mr. Ritvo talked about his work and illness in interviews on radio programs including "Only Human" on WNYC and "The New Yorker Radio Hour." His poems have appeared in Poetry Magazine and The New Yorker, and his first published volume of poetry, "Four Reincarnations," will appear in the fall.

The poet Louise Glück, who taught Mr. Ritvo at Yale, called the book "one of the most original and ambitious first books in my experience," adding that his work is "marked by intellectual bravado and verbal extravagance."

Mr. Ritvo was 16 when he learned he had Ewing's sarcoma, a rare pediatric cancer. He had gone to doctors after feeling pain in his side. At first they suspected pneumonia, but fearing something worse they took a tissue sample while he was under sedation.

He woke up in a cancer ward.

"I remember thinking, 'This is so terrible!'" he told Mary Harris of WNYC. "'I'm just a young, acrobatic, wiry, handsome bloke of 16, and it's so sad for all these old people, because they must have run out of beds and I just have pneumonia.'"

A year of aggressive treatment brought about remission, and over the next four and a half years he finished high school and attended Yale.

The cancer returned in Mr. Ritvo's senior year. He nevertheless completed his degree in 2013 and this year earned a master of fine arts from Columbia University, where he became a teaching fellow. He also served as poetry editor at Parnassus: Poetry in Review.

Throughout his illness, he rejected the clichés of being an "inspiring victim of cancer," his mother said. He counseled other families going through treatment for Ewing's sarcoma, and spoke out often about the disease and the importance of research.

Sunday, October 2, 2016

For most of my adult life I have answered the question "Occupation?" with one word: journalist. I still do, but now I am tempted to add a phrase.

Cancer patient.

Three years ago, at age 73, I learned that I had an incurable cancer called multiple myeloma. At the time the statistical life span for patients with the disease was five years.

That number has not changed, but I have. After three years of chemotherapy, a spinal operation that cost me three inches of height, monthly infusions of bone supplements and drugs to prevent respiratory infection, I am now almost as close to 80 as I was to 70 at the time of the diagnosis. I have lived 60 percent of those five years.

The cancer is in remission, and I take the word of my medical team that I am doing well and should beat the standard life expectancy. I still lead a busy professional and personal life. Biking, swimming, fly-fishing and bird hunting remain active interests — but in a new context.

Even in remission, cancer alters a patient's perception of what's normal. Morning, noon and night, asleep and awake, malignant cells are determined to alter or end your life. Combating cancer is a full-time job that, in my case, requires 24 pills a day, including one that runs $500 a dose. For me, bone damage brought persistent back pain and unwelcome muscle deterioration.

Constant fatigue is a common signature of cancer patients, which separates them from healthy friends and family members. It is also what brings cancer patients together.

Tuesday, September 27, 2016

Surah Grumet used to be a family doctor at a clinic in the Bronx. "It always felt like I was trying to catch up," she said. "I was always falling behind, and it was so stressful. And it was really hard to bring up my two girls, to be there for them, and still be able to practice medicine the way that I wanted to."

Now, she lives in a suburb of Raleigh, N.C. She still practices medicine, but has no office or clinic. Instead, she works with a Durham-based practice called Doctors Making House Calls.

Grumet puts her girls on the school bus and gets in the car just before nine. Her patients are frail elderly people with multiple chronic illnesses: memory loss, heart and blood pressure problems, arthritis that makes mobility difficult.

Grumet works full time, but on her own schedule. She can spend 15 minutes with a patient, or nearly two hours. She's home before the school bus and completes her patient notes and paperwork while her girls do homework. She makes $70,000 more than she did when she worked in the Bronx.

How is this possible? In a world where many doctors struggle to make money seeing four patients an hour, how can they run a successful practice driving to patients' homes and spending all the time their patients need?

Before 1950, nearly half of all doctors' visits in America were house calls. But then the country began building big hospitals and luxurious doctors' offices, and doctors acquired sophisticated equipment they couldn't put in a medical bag. Medicare and Medicaid reimbursement systems made home visits untenable.

But the house call is now a better idea than ever.

To cut America's health care costs, it helps to look at the most expensive patients. Medicare spends a third of its budget caring for chronically ill people in their last two years of life. This group is growing fast, and growth will accelerate; the first baby boomers are now turning 70.

Monday, September 26, 2016

The University of Vermont College of Medicine is changing the way physicians are trained by switching exclusively to a hands-on approach to learning designed to encourage students to solve medical puzzles rather than just memorizing body parts and diseases.

While most medical schools recognize the importance of active learning and use it in some of their classes, UVM is believed to be among the first in the country to commit itself to switching all its medical training to the new system.

"Shifting completely away from the traditional lectures in that way, we are not familiar with any other medical school that has done that across all four years," said Lisa Howley, the senior director of educational affairs at the Washington-based Association of American Medical Colleges, which represents 145 medical schools and about 400 teaching hospitals.

The effort will get a boost from a $66 million donation from 1942 medical school graduate Robert Larner that will provide $4 million a year in perpetuity to help implement the changes. In announcing the donation Friday, the medical school, which has about 465 students, also said it was changing its name to The Robert Larner M.D. College of Medicine.

Making the switch presents a challenge to an educational system that, especially in the early years of medical school, relied on a doctor lecturing to students from the front of the room.

William Jeffries, associate dean at the UVM medical school, points to a 2014 study in the Proceedings of the National Academy of Sciences that determined students in traditional lectures were 1.5 times more likely to fail than students taught with active learning.

"If this was a clinical trial of a new drug or a treatment, we would adopt it because we knew that the other method was inferior to the first method," Jeffries said. "We have to react to that evidence."

Here's how the process works in the new system:

In class, medical students might be given a case in which a patient is complaining of arm pain. The students would focus on which bone is most likely broken and the possible implications of the injury to the circulatory or nervous system.

"That means they have to know the anatomy, and then they have to say, 'Well, in the real world, what are we going to do with that information?" said Dr. William Raszka, a pediatrician who teaches in the medical school.

"The family doesn't come in and say, 'I think my ulna's fractured.' They say, 'My son came in, he fell off the jungle gym and he's holding his hand,"' Raszka said.

To facilitate those types of discussions, the school is removing lined-up desks from classrooms and replacing them with tables where small groups of students can apply the information they learn before class and work together to find answers to questions posed by the teachers. The rarely used books in the medical school library are going to be moved into storage and the information digitized.

You must lose weight, a doctor told Sarah Bramblette, advising a 1,200-calorie-a-day diet. But Ms. Bramblette had a basic question: How much do I weigh?

The doctor's scale went up to 350 pounds, and she was heavier than that. If she did not know the number, how would she know if the diet was working?

The doctor had no answer. So Ms. Bramblette, 39, who lived in Ohio at the time, resorted to a solution that made her burn with shame. She drove to a nearby junkyard that had a scale that could weigh her. She was 502 pounds.

One in three Americans is obese, a rate that has been steadily growing for more than two decades, but the health care system — in its attitudes, equipment and common practices — is ill prepared, and its practitioners are often unwilling, to treat the rising population of fat patients.

The difficulties range from scales and scanners, like M.R.I.machines that are not built big enough for very heavy people, to surgeons who categorically refuse to give knee or hip replacements to the obese, to drug doses that have not been calibrated for obese patients. The situation is particularly thorny for the more than 15 million Americans who have extreme obesity — a body mass index of 40 or higher — and face a wide range of health concerns.

Part of the problem, both patients and doctors say, is a reluctance to look beyond a fat person's weight. Patty Nece, 58, of Alexandria, Va., went to an orthopedist because her hip was aching. She had lost nearly 70 pounds and, although she still had a way to go, was feeling good about herself. Until she saw the doctor.

"He came to the door of the exam room, and I started to tell him my symptoms," Ms. Nece said. "He said: 'Let me cut to the chase. You need to lose weight.'"

The doctor, she said, never examined her. But he made a diagnosis, "obesity pain," and relayed it to her internist. In fact, she later learned, she had progressive scoliosis, a condition not caused by obesity.

Dr. Louis J. Aronne, an obesity specialist at Weill Cornell Medicine, helped found the American Board of Obesity Medicine to address this sort of issue. The goal is to help doctors learn how to treat obesity and serve as a resource for patients seeking doctors who can look past their weight when they have a medical problem.

Sunday, September 25, 2016

"Half my life has been about trying to lose weight," Henry Roberts said. He was telling me about his decision to have a surgery that would reduce the size of his stomach by seventy-five per cent. Roberts (a pseudonym) is five feet six, and when we met he weighed two hundred and seventy pounds, giving him a body-mass index of forty-four; a B.M.I. between eighteen and a half and twenty-five is considered healthy. "I tried every diet, every regimen. I even had urine from a pregnant woman injected into me—that was a fad once. Have you ever tried a Weight Watchers cannoli? Weight Watchers didn't work for me, either, and I found the meetings humiliating." Roberts, who is sixty-eight and retired from his job as a public-school guidance counsellor, lives in an immaculate, art-crowded apartment in the West Village. He recently went through the breakup of a long-term relationship, but he remains close friends with his ex-boyfriend. Roberts grew up in Queens, the son of an M.T.A. worker who avoided the chemicals in canned foods "before that was fashionable," he said. Decades ago, he successfully quit smoking and drinking. Managing his weight has been more difficult. "You can't just quit eating altogether," he said. He had opted for a procedure called a sleeve gastrectomy—the stomach is surgically narrowed to resemble a sleeve—but this was not Roberts's first attempt at a surgical treatment for obesity. "I can't remember the exact year, but I know I had the lap-band procedure the weekend that Michael Jackson died," he told me. The laparoscopic gastric-band procedure worked for Roberts for about a year, but then he began to regain weight.

Thursday, September 22, 2016

For the fourth time in its history, the United Nations has elevated a health issue to crisis level.

The UN General Assembly held a high-level meeting earlier this week(Sept. 21) to address how antibiotics have become less useful when treating human illnesses caused by bacteria. In its 70 year history the General Assembly has called similar meetings to discuss HIV, the rise of non-communicable diseases such as heart disease, and Ebola.

By pushing antibiotic resistance front-and-center as a global problem, the international body has acknowledged that some of the miracles of modern medicine—including the invention of penicillin and tetracyclines—are at risk of becoming ineffective. Already the US Centers for Disease Control and Prevention estimates that 23,000 people die in the US each year as a direct result of antibiotic resistance. Some of those deaths were from illnesses once easily treated with the drugs, including MRSA and some E. coli infections.

Thursday, September 15, 2016

A new study offers important information to men who are facing difficult decisions about how to treat prostate cancer in its early stages, or whether to treat it at all.

Researchers followed patients for 10 years and found no difference in death rates between men who were picked at random to have surgery or radiation, or to rely on "active monitoring" of the cancer, with treatment only if it progressed.

Death rates from the cancer were low over all: only about 1 percent of patients 10 years after diagnosis.

But the disease was more likely to progress and spread in the men who opted for monitoring rather than for early treatment. And about half the patients in the study who had started out being monitored wound up having surgery or radiation.

The patients are still being followed, which should reveal whether the death rate will eventually increase for the men assigned to monitoring.

Doctors say the findings should help reassure men that surgery and radiation are equally reasonable choices in the early stages of the disease.

"I can counsel patients better now," Dr. Freddie C. Hamdy, a leader of the study from the University of Oxford, in England, said in an interview. "I can tell them very precisely, 'Look, your risk of dying from cancer is very, very small. If you receive treatment you will get some benefit. It will reduce the disease from growing outside your prostate, but these are exactly the side effects you might expect.'"

Monday, September 12, 2016

The Stand Up to Cancer (SU2C) telethon is tonight, and the hour-long TV event promises to offer a mix of inspiring cancer survivors and celebrities like Jon Hamm and Kristen Wiig hailing the accomplishments of the eight-year-old fundraising outfit, which has hauled in $370 million for oncology research so far. There's little doubt that cancer research benefits from such high-profile efforts to bring in more funding. SU2C-supported researchers, for example, had a hand in the recent FDA approvals of Pfizer's Ibrance (palbociclib) to treat breast cancer and Celgene's Abraxane (paclitaxel) plus gemcitabine to treat pancreatic cancer. But there's a flipside to more cancer patients surviving the disease—and it's one that the National Cancer Institute (NCI) says deserves more scrutiny.

First, the good news: The NCI predicts that the number of cancer survivors in the U.S. will jump from 15.5 million to 26.1 million by 2040, fueled in part by the graying of the Baby Boomer population, but also by the growth of new, more effective treatments, according to a study published in a recent edition of the American Association for Cancer Research journal Cancer Epidemiology, Biomarkers & Prevention.

Will ever-more sensitive screening tests for cancer lead to longer, better lives? Will anticipating and trying to prevent the future complications of chronic disease lead to better health? Not always, says Robert Aronowitz in Risky Medicine. In fact, it often is hurting us.

Exploring the transformation of health care over the last several decades that has led doctors to become more attentive to treating risk than treating symptoms or curing disease, Aronowitz shows how many aspects of the health system and clinical practice are now aimed at risk reduction and risk control. He argues that this transformation has been driven in part by the pharmaceutical industry, which benefits by promoting its products to the larger percentage of the population at risk for a particular illness, rather than the smaller percentage who are actually affected by it. Meanwhile, for those suffering from chronic illness, the experience of risk and disease has been conflated by medical practitioners who focus on anticipatory treatment as much if not more than on relieving suffering caused by disease. Drawing on such controversial examples as HPV vaccines, cancer screening programs, and the cancer survivorship movement, Aronowitz argues that patients and their doctors have come to believe, perilously, that far too many medical interventions are worthwhile because they promise to control our fears and reduce uncertainty.

Edwina Kirby was having a hard time. She had tripped over a rug in her home in Livonia, Mich., and the fall broke a femur. After she had surgery and rehabilitation, an infection sent her back into the hospital. Her kidneys failed, requiring dialysis; she was also contending with diabetes and heart disease.

By the time she entered Glacier Hills Care and Rehabilitation Center, a nursing facility in Ann Arbor, "she couldn't even feed or dress herself," said her daughter Deanna Kirby, 55. "She was basically bedridden."

For months, physical therapists worked with Mrs. Kirby, a retired civil servant who is now 75, trying to help her regain enough mobility to go home. Then her daughter received an email from one of the therapists saying, "Edwina has reached her highest practical level of independence."

Translation: Mrs. Kirby wouldn't receive Medicare coverage for further physical therapy or for the nursing home. If she wanted to stay and continue therapy, she'd have to pay the tab herself.

Medicare beneficiaries often hear such rationales for denying coverage of skilled nursing, home health care or outpatient therapy: They're not improving. They've "reached a plateau." They're "stable and chronic," or have achieved "maximum functional capacity."

She's right. A federal judge last month ordered the federal Centers for Medicare and Medicaid Services to do a better job of informing health care providers and Medicare adjudicators that the so-called improvement standard was no longer in effect.

Sunday, September 11, 2016

One of Donald J. Trump's recent attack lines against Hillary Clinton focuses on her health: If she has nothing to hide, he asks in a tweet, why doesn't she release her medical records to the public?

For the moment, put aside Mr. Trump's own revelations about his medical history, which consist of a hyperbolic, undated letter with little detail from his gastroenterologist. And put aside Mrs. Clinton's own recent disclosures, which include a somewhat more detailed accounting of her health and medication history from the internist who has overseen her care in recent years. Put aside, finally, the question of whether complete medical records would allay the conspiracy theories of some of Mrs. Clinton's critics, who say a recent cough is a sign of disqualifying illness or believe she experienced a seizure during a recent news conference.

Instead, assume that Mrs. Clinton wished to take Mr. Trump's request seriously, and release full and detailed medical records. It would not be easy, even for a V.I.P. with an army of staffers. Mrs. Clinton is 68 years old, has lived in multiple states and been treated by many doctors and hospitals over the years. The notion of a single file, containing "medical records," is a fiction. Her medical records are in bits and pieces, in doctors' filing cabinets, hospital records departments, and in hard-to-access computers. Just like yours, probably.

The federal government has invested billions in helping to digitize medical records, but the process is still in its infancy, with data that is often nonstandard and hard to transfer between systems. And even as a growing number of medical professionals have made the transition to digital records, most of our medical histories exist only in the old world of paper, assuming they still exist at all. (Mrs. Clinton's pediatrician is unlikely to still be alive, and records of Mrs. Clinton's possible polio vaccination or childhood ear infections may be lost to history.)

Cholesterol-lowering drugs called statins​ have gotten a bad rap, say the authors of a comprehensive new review of 30 years' worth of studies on the medications. Statins – including such popular brand names as Lipitor, Crestor, Zocor and Pravachol – are taken by millions of people​.

The research, published today in The Lancet, will help doctors and patients make more informed decisions when it comes to using statins, the scientists said in a media briefing.

The review focused on the results of randomized clinical trials and other evidence on the effectiveness and safety of statin therapy.

"Our review shows that the numbers of people who avoid heart attacks and strokes by taking statin therapy​ are very much larger than the numbers who have side-effects with it," review author Dr. Rory Collins, of the University of Oxford, in England, said in a press statement. "In addition, whereas most of the side effects can be reversed with no residual effects by stopping the statin, the effects of a heart attack​ or stroke​ not being prevented are irreversible and can be devastating."

In their paper, the authors said lowering cholesterol by prescribing a standard 40-milligram daily dose of atorvastatin (generic for Lipitor) would, over the course of five years in 10,000 patients, prevent heart attacks, ischemic strokes and coronary artery bypasses in 1,000 people with pre-existing vascular disease. The drug would prevent those conditions in 500 additional people who are at an increased risk – due to age, hypertension or diabetes – but who haven't yet had a vascular event.

On the other hand, while statins can have some serious side effects, the researchers found the numbers are tiny in comparison. The same dose over the same period of time in the same number of patients would lead to five cases of patients developing muscle pain and weakness​ (myopathy). And only about one of those cases would result in full-blown muscle breakdown, called rhabdomyolysis​, if the drug treatment continued.

Wednesday, September 7, 2016

In 1991 previously healthy young women in Brussels started showing up at clinics with advanced kidney damage. An inquiry revealed that they had all attended the same weight-loss program and, due to a mix-up, had received the Chinese herb Aristolochia as part of the regimen. More than 100 women developed irreversible kidney damage requiring dialysis or transplantation, and a high percentage went on to develop cancer of the upper urinary tract.

Had it not been for the unusual nature of the outbreak and alert clinicians, the incident might well have gone unnoticed. As it turned out, the Brussels cluster dramatized in an unprecedented way the previously unacknowledged threat that can be posed by herbal remedies.

In the 25 years since the Brussels outbreak, we have learned a great deal about the use and harmful effects of toxic herbs. This knowledge, however, has not translated into policies to reduce the harm caused by botanicals. Instead, the World Health Organization has launched an ambitious program that flies in the face of the scientific evidence the organization demands elsewhere and shamelessly promotes the use of traditional medicine, including herbal treatments, that could be dangerous.

Tuesday, September 6, 2016

On Thursday, we challenged Well readers to take on the complicated case of a 50-year-old woman who felt feverish and couldn't stop vomiting and who ended up losing a lot of weight. Like the doctors who saw her as she searched for a diagnosis, many of you focused on her recent journey to Kenya as the source of her symptoms. It was a completely reasonable approach, and one that was extensively explored by the doctors who cared for her. But ultimately it was incorrect.

Every year, Americans spend at least $20 billion on unnecessary medical visits in the US. This is one of the drivers behind the spiraling cost of health care, which is predicted to soar to $5.5 trillion by 2024. The last thing you'd imagine is that the internet would have anything to do with this. But guess again.

Medical doctors are already aware of the connection, because they see it every day. Patients arrive at offices and clinics with a "Google stack," as it's sometimes called: a pile of print-outs from the online research they've done that has led them to form their own amateur medical opinion.

Seventy-two percent of Americans search for health information online, according to a 2013 Pew study. About 35% search for diagnostic information, and of those who attempt to self-diagnose, just over half proceed to make an appointment with a medical professional to talk about what they found online. In June 2016, Google reported that roughly 1% the site's searches are related to medical symptoms.

For a number of reasons, most medical professionals aren't too happy about the self-diagnosis trend. It isn't simply a matter of loss of control or an undermining of their authority though online medical searches—it can mess with the diagnostic process, because the results can suggest rare or morbid conditions to patients, which in turn can prompt the appearance of new "symptoms." You search online for "sore throat," for instance, and find yourself engrossed and horrified by descriptions of esophageal cancer. Your anxiety escalates.

There was no mistaking the diagnostic significance of that little red stick inside a deep blue cell: The Auer rod meant the mystery patient had acute myelogenous leukemia. As slide after slide went by, her bone marrow told a story: treatment, remission, relapse, treatment, remission, remission, remission.

I was reading these marrows in 1987, but the samples had been drawn in 1978 and 1979. Median survival of that lethal disease with treatment was about 18 months; however, given that she had already relapsed once, I knew that she had to be dead. Probably someone was being sued, and that was why my hematology colleagues had asked for a blind reading.

Imagining an aggressive cross-examination in court, I emphasized in my report that I knew neither the history nor why I was reading the marrows. After the work was submitted, I asked the treating physician what was going on. She smiled and said that my report had been sent to the Vatican. This leukemia case was being considered as the final miracle in the dossier of Marie-Marguerite d'Youville, the founder of the Order of Sisters of Charity of Montreal and a candidate to become the first Canadian-born saint.

Sunday, September 4, 2016

First you get your coat. I don't care if you don't remember where you left it, you find it. If there was a lot of blood you ask someone to go quickly to the basement to get you a new set of scrubs. You put on your coat and you go into the bathroom. You look in the mirror and you say it. You use the mother's name and you use her child's name. You may not adjust this part in any way.

I will show you: If it were my mother you would say, "Mrs. Rosenberg. I have terrible, terrible news. Naomi died today." You say it out loud until you can say it clearly and loudly. How loudly? Loudly enough. If it takes you fewer than five tries you are rushing it and you will not do it right. You take your time.

After the bathroom you do nothing before you go to her. You don't make a phone call, you do not talk to the medical student, you do not put in an order. You never make her wait. She is his mother.
When you get inside the room you will know who the mother is. Yes, I'm very sure. Shake her hand and tell her who you are. If there is time you shake everyone's hand. Yes, you will know if there is time. You never stand. If there are no seats left, the couches have arms on them.

You will have to make a decision about whether you will ask what she already knows. If you were the one to call her and tell her that her son had been shot then you have already done part of it, but you have not done it yet. You are about to do it now. You never make her wait. She is his mother. Now you explode the world. Yes, you have to. You say something like: "Mrs. Booker. I have terrible, terrible news. Ernest died today."

Friday, September 2, 2016

Karen Franklin leans against the sink in the pink-tiled bathroom of her childhood home, counting out pills. There's a purple morphine tablet for chronic back pain, a blue Xanax for anxiety and a white probiotic for her stomach, which aches from all the other pills.

In all, Franklin, 60, takes more than a dozen different prescription drugs, washing them down with tap water and puffing on a Marlboro while she waits for them to kick in.

"They take the edge off, but that's about it," Franklin says. So she keeps a bottle of vodka handy for added relief, increasing her risk of joining the legions of American women dying from prescription-drug overdoses.

While death rates are falling for blacks and Hispanics in middle age, whites are dying prematurely in growing numbers, particularly white women. One reason: a big increase in overdoses, primarily from opioids, but also from anti-anxiety drugs, which are often prescribed in tandem.

Between 1999 and 2014, the number of middle-aged white women dying annually from opiate overdoses shot up 400 percent, according to a Washington Post analysis of data from the Centers for Disease Control and Prevention. Anti-anxiety drugs known as benzodiazepines contributed to a growing share of the 54,000 deaths over that period, reaching a third in the last several years, The Post found, though spotty reporting in death records makes it likely that the combination is even more widespread.

Both drugs depress the central nervous system, temporarily easing pain and anxiety while suppressing respiration, heart rate and the gag reflex. Alcohol has the same effect, and combining any of these can be fatal.

"They act like a dimmer switch on the central nervous system," said Rear Admiral Susan Blumenthal, former U.S. assistant surgeon general and an expert on women's health issues. "When taken in combination, a person's breathing and heart will slow down, and can ultimately stop. People can go to sleep and never wake up."

White women are more likely than women of other races to be prescribed opiates, and far more likely to be prescribed both opiates and anti-anxiety drugs, according to a Post analysis of middle-aged participants in the latest National Health and Nutrition Examination Survey. White women prescribed opiates are five times as likely as white men to be given that drug combination — helping to explain why white women may be at special risk.

At least eight pharmaceutical companies sell a decades-old drug that treats gallstones, but the competition has done little to keep its price down.

Instead the price has skyrocketed.

Two years ago, ursodiol's wholesale price was as low as 45 cents a capsule. Then in May 2014, generic drug manufacturer Lannett Co. hiked its price to $5.10 per capsule, and one by one its competitors followed suit – with most charging nearly the same price.

Experts say this is not how a competitive marketplace is supposed to work.

"When you have a generic drug with eight suppliers you would expect the prices to go down," said Dana Goldman, director of USC's Leonard D. Schaeffer Center for Health Policy & Economics.

Unlike nearly every other developed nation, the U.S. allows drug manufacturers to set their own prices, a policy that has resulted in overall medicine costs being far higher than elsewhere. Increasingly, insurers are passing the cost along to patients through higher deductibles.

Robert Frankil, the owner of Sellersville Pharmacy in Pennsylvania, said ursodiol is just one of dozens of generic drugs that he has found to spike in price in the last couple of years.

"Why are these companies raising their prices?" asked Frankil. "Because they can."

Saturday, August 27, 2016

In the late 1930s, Charles Bradley, the director of a home for "troublesome" children in Rhode Island, had a problem. The field of neuroscience was still in its infancy, and one of the few techniques available to allow psychiatrists like Bradley to ponder the role of the brain in emotional disorders was a procedure that required replacing a volume of cerebrospinal fluid in the patient's skull with air. This painstaking process allowed any irregularities to stand out clearly in X-ray images, but many patients suffered excruciating headaches that lasted for weeks afterward.

Meanwhile, a pharmaceutical company called Smith, Kline & French was facing a different sort of problem. The firm had recently acquired the rights to sell a powerful stimulant then called "benzedrine sulfate" and was trying to create a market for it. Toward that end, the company made quantities of the drug available at no cost to doctors who volunteered to run studies on it. Bradley was a firm believer that struggling children needed more than a handful of pills to get better; they also needed psychosocial therapy and the calming and supportive environment that he provided at the home. But he took up the company's offer, hoping that the drug might eliminate his patients' headaches.

It did not. But the Benzedrine did have an effect that was right in line with Smith, Kline & French's aspirations for its new product: The drug seemed to boost the children's eagerness to learn in the classroom while making them more amenable to following the rules. The drug seemed to calm the children's mood swings, allowing them to become, in the words of their therapists, more "attentive" and "serious," able to complete their schoolwork and behave. Bradley was amazed that Benzedrine, a forerunner of Ritalin and Adderall, was such a great normalizer, turning typically hard-to-manage kids into models of complicity and decorum. But even after marveling at the effects of the drug, he maintained that medication should be considered for children only in addition to other forms of therapy.

Bradley's research was ignored for a couple of decades as psychoanalysis became dominant in the United States. But his discoveries laid the foundation for one of the most aggressive marketing campaigns in history, which succeeded not only in helping to transform the nascent drug industry into the multinational juggernaut known as Big Pharma, but in convincing parents, physicians and ­public health officials that 15 percent of American schoolchildren are sick enough that they would require powerful medication just to get through the day.

Thursday, August 25, 2016

There is something about the ER—especially the night shift—that thrives on spontaneity.

It's just past 2 a.m. I meet him for the first time in a hallway stretcher—one step past the waiting room and any number of hours before he inherits a bed with privacy. The patient is a 50-something Caucasian man with salt-and-pepper hair, battered glasses, a three-day beard, and an air of frustration. He wants to know why—why the long wait, why he's constantly in pain, and why we can't immediately comply with his request for narcotics.

I start to gather information as we are trained to do. I utter some version of "what brings you into the ER today?" I carry on with more questions, registering each answer on my mental checklist.

"Look, I really don't want to be here right now," he says with defeat.

I pause.

I tuck away my pen and paper—and with them, my persistence.

"You know, to be honest, I wouldn't mind being at home in my own bed right now either," I offer.

A major study about the best way to treat early-stage breast cancer reveals that "precision medicine" doesn't provide unambiguous answers about how to choose the best therapy.

"Precision doesn't mean certainty," says David Hunter, a professor of cancer prevention at Harvard's T.H. Chan School of Public Health.

That point is illustrated in a large study published Wednesday in the New England Journal of Medicine, involving decisions about chemotherapy.

As is true for many cancers, breast cancer responds best to treatment when it is caught early, before it has spread throughout the body. Dr. Fatima Cardoso, the study's lead author and a breast cancer specialist at the Champalimaud Clinical Center in Lisbon, Portugal, says that creates a conundrum for doctors and patients alike.

Because it's the only opportunity to cure the cancer, "when in doubt we tend to treat" women with early-stage breast cancer, she told Shots. "So we know that we overtreat the patients with early breast cancer."

That means that women could end up undergoing chemotherapy even if it wouldn't really improve their survival odds.

Hoping to refine those treatment decisions, Cardoso helped organize a huge study throughout Europe to see whether a commercially available genetic test called MammaPrint could help reduce that overtreatment. More than 6,600 women participated at 112 institutions in nine nations.

Scientists identified women with breast cancer whose physical exams suggested they were at relatively high risk for having the cancer return eventually after surgery, but who seemed to be at low risk of recurrence based on the genetic test results.

They were invited to participate in the study, which would randomly assign them to have chemotherapy or not. "You know that chemotherapy is a treatment that scares people, so overall and for the majority of patients, it was not difficult to convince them," Cardoso says.

The genomic test, which studies 70 distinct features of a tumor, did a pretty good job of predicting who was at low risk for recurrence of breast cancer and could therefore avoid the pain, discomfort and risks of chemotherapy. (The test, priced at $4,200, is covered by some insurance in the United States.)

The scientists found that 46 percent of women who were deemed to be at high risk of recurrence based on physical symptoms could actually skip chemotherapy with little consequence to their long-term survival.

Wednesday, August 24, 2016

There's an exceedingly simple way to get better health care: Choose a better hospital. A recent study shows that many patients have already done so, driving up the market shares of higher-quality hospitals.

A great deal of the decrease in deaths from heart attacks over the past two decades can be attributed to specific medical technologies like stents and drugs that break open arterial blood clots. But a study by health economists at Harvard, M.I.T., Columbia and the University of Chicago showed that heart attack survival gains from patients selecting better hospitals were significant, about half as large as those from breakthrough technologies.

That's a big improvement for nothing more than driving a bit farther to a higher-quality hospital.

Tuesday, August 23, 2016

The 41-year-old management analyst for the Navy had grown accustomed to periodic bouts of neuropathy — numbness in her hands and feet — the apparent legacy of a severe allergic reaction to a drug she took in 2000 to treat a gynecological infection.

But this 2015 episode was different. Along with the sensation that her feet felt unusually warm, the skin on the second toe of her right foot looked inflamed. Weeks later, she noticed a small blister.

Bogner, who lives in Southern Maryland, initially shrugged it off. She figured that whatever was wrong would go away on its own.

Saturday, August 20, 2016

Imagine this: You're a cardiac surgeon who is pushing into the five-hour mark of a complicated seven-hour surgery. You ask a nurse for a specific tool, and he drops it. It's now contaminated and useless. The nurse stands dumbstruck until you snap at him to hurry up, grab another tool, and stop being so clumsy. You were rude, but he deserved it, right? He'll get over the uncivil remark and everybody will move on. But that "moving on" actually might not happen — according to a recent study, rude comments in high-pressure medical settings could have potentially deadly effects on patients.

The study, "The Impact of Rudeness on Medical Team Performance: A Randomized Trial," which was published in the September issue of Pediatrics, shows that a rude comment from a third-party doctor decreased performance among doctors and nurses by more than 50 percent in an exercise involving a hypothetical life-or-death situation. "We found that rudeness damages your ability to think, manage information, and make decisions," said Amir Erez, an author on the study and a Huber Hurst professor of management at the University of Florida. "You can be highly motivated to work, but if rudeness damages your cognitive system then you can't function appropriately in a complex situation. And that hurts patients."

For the experiment, Erez and his colleagues gave 24 medical teams from neonatal intensive care units in Israeli hospitals, each composed of one doctor and two nurses, an hour to diagnose and treat a simulated case of necrotizing enterocolitis, a rapid and potentially fatal disease in which a premature newborn's intestinal tissue becomes inflamed and starts to necrotize, or die.

Before beginning, the teams were informed that a leading ICU expert from the United States would be observing them via webcam. The researcher running the experiment then dialed a fake phone number and played a (prerecorded) message that was supposedly from the observer. The message informed half of the participants that he had observed other medical teams and was "not impressed with the quality of medicine in Israel," but told the control group simply that he had observed other teams, without making any rude comments or insults. Ten minutes into the simulation the teams were interrupted by another prerecorded message from the researcher. He told the control group that he hoped the workshop helped them improve as physicians; he told the other teams, however, that the Israeli physicians and nurses he'd been observing "wouldn't last a week" in his department.

ConsumerMedSafety.org is provided to you by the Institute for Safe Medication Practices (ISMP). This unique website is designed to help you, the consumer, avoid mistakes when taking medicines. Preventing medication errors is a huge responsibility that doctors, pharmacists, and nurses take seriously. But you, too, can play a vital role in preventing dangerous errors, and ConsumerMedSafety.org is exactly what you need to protect yourself and your loved ones!

The majority of the material provided on our website, is original, written by the ISMP staff. Content is developed from

• Reports submitted to the Medication Error Reporting Program (MERP) by practitioners and consumers with research by our editorial staff to confirm and validate.
• Shared work from our newsletter publications, including the ISMP Medication Safety Alert! For acute care hospitals, a consumer newsletter, a community pharmacy/medicine newsletter and a nursing newsletter.

• Independent articles developed, produced and edited entirely for consumermedsafety by ISMP staff.
• Some information, as noted on the website, is shared with us by the US Food and Drug Administration.
• Occasionally, consumermedsafety will make mention of an article from which the topic is derived. In all cases we include the source material.

Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

"This is actually a little bit alarming," said Bailey, a pharmacist.

He was concerned about the sheer number of drugs but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal's breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don't communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

"This is America's other drug problem — polypharmacy," said Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica, Calif. "And the problem is huge."

Tuesday, August 16, 2016

Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

Tuesday, August 9, 2016

TOWSON, Md. — Two days into a long-dreamed-of family vacation to Italy in August 2013, my wife, Ronna, became nauseated, unusually tired and short of breath. One of the great non-complainers in American history, she insisted that it was no big deal and valiantly tried to join in on various outings in the Italian countryside. But, after a few increasingly difficult days, even Ronna knew that it was time to go to the emergency room.

In a small hospital in Tuscany, doctors identified the apparent source of the problem: a pericardial effusion, or a buildup of fluid around the heart. Ronna was transferred to a larger medical center in Arezzo, where a pericardial tap was performed. Immediately afterward, in a scene that still plays on a loop in my mind's eye, the hospital's chief of cardiology informed me that, while the fluid was gone, he was quite sure that Ronna had lung cancer.

A few weeks later, when we were back home in Maryland, doctors at Johns Hopkins Hospital confirmed his suspicion: My healthy, active, 48-year-old, never-smoker wife had Stage 4 non-small cell lung cancer.

Over the next two years, Ronna underwent several rounds of grueling chemotherapy and, when the cancer spread to her brain, several rounds of radiation treatment. She also took part in a clinical trial at Johns Hopkins for Opdivo, an immunotherapy drug made by the pharmaceutical company Bristol-Myers Squibb. Briefly stated, immunotherapy is a recently developed, highly promising treatment that helps a person's immune system identify and attack cancer cells. But it did not work for Ronna, and last Sept. 25 she died as her parents and I held her hands and whispered in her ear.

Needless to say, it has been a difficult year for my two children and me. But, knowing that Ronna couldn't abide self-pity, we have been slowly moving forward by doing our best to cope and trying to honor, whenever possible, her remarkable memory and legacy.

A few weeks ago, though, I saw a television commercial that dealt that process a setback. It was a 90-second ad for Opdivo that began with soaring music and shots of older people in warm sunlight, gazing upward at a building on which the words "A chance to live longer" were superimposed. The voice-over said, "Opdivo significantly increased the chance of living longer versus chemotherapy." The wording may be a little clumsy, but the velvet-voiced narrator made his point, bolstered by actors portraying lung cancer patients playing with babies and watching Little League games.

It would be incredibly uplifting if it weren't so utterly misleading and exploitive. To date, only about one in five patients with Stage 4 non-small cell lung cancer has seen any measurable response to Opdivo; and, in those patients who do respond, the median increase in life expectancy is only about three months compared with standard chemotherapy.

Sunday, August 7, 2016

Before a drug can be marketed, it has to go through rigorous testing to show it is safe and effective. Surgery, though, is different. The Food and Drug Administration does not regulate surgical procedures. So what happens when an operation is subjected to and fails the ultimate test — a clinical trial in which patients are randomly assigned to have it or not?

The expectation is that medical practice will change if an operation turns out not to help.
If only.

It looks as if the onus is on patients to ask what evidence, if any, shows that surgery is better than other options.

Take what happened with spinal fusion, an operation that welds together adjacent vertebrae to relieve back pain from worn-out discs. Unlike most operations, it actually was tested in four clinical trials. The conclusion: Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. In both groups, the pain usually diminished or went away.

The studies were completed by the early 2000s and should have been enough to greatly limit or stop the surgery, says Dr. Richard Deyo, professor of evidence-based medicine at the Oregon Health and Sciences University. But that did not happen, according to a recent report. Instead, spinal fusion rates increased — the clinical trials had little effect.

Saturday, July 30, 2016

Steve Cara expected to sail through the routine medical tests required to increase his life insurance in October 2014. But the results were devastating. He had lung cancer, at age 53. It had begun to spread, and doctors told him it was inoperable.

A few years ago, they would have suggested chemotherapy. Instead, his oncologist, Dr. Matthew D. Hellmann of Memorial Sloan Kettering Cancer Center in New York, recommended an experimental treatment: immunotherapy. Rather than attacking the cancer directly, as chemo does, immunotherapy tries to rally the patient's own immune system to fight the disease.

Uncertain, Mr. Cara sought a second opinion. A doctor at another major hospital read his scans and pathology report, then asked what Dr. Hellmann had advised. When the doctor heard the answer, Mr. Cara recalled, "he closed up the folder, handed it back to me and said, 'Run back there as fast as you can.'"

Many others are racing down the same path. Harnessing the immune system to fight cancer, long a medical dream, is becoming a reality. Remarkable stories of tumors melting away and terminal illnesses going into remissions that last years — backed by solid data — have led to an explosion of interest and billions of dollars of investments in the rapidly growing field of immunotherapy. Pharmaceutical companies, philanthropists and the federal government's "cancer moonshot" programare pouring money into developing treatments. Medical conferences on the topic are packed.

Thursday, July 28, 2016

Health regulators in the United States are talked about as the best in the world, but a new study on the spread of stem cellclinics shows what can happen when regulations fall behind.

Out of nowhere, over the past two to three years, the clinics have sprung up — 570 in the United States, according to a recent paper — offering untested stem cell treatments for just about every medical use imaginable.

In theory, stem cells might be a useful treatment for certain diseases that involve the loss of cells, like Type 1 diabetes, Parkinson's or osteoarthritis. They are primitive cells that can develop into a range of mature cells and perhaps serve as replacements. But progress is slow. After a flurry of stem cell excitement two decades ago, almost all the research today is still in mice or petri dishes. The very few clinical trials that have begun are still in the earliest phase.

The problem is that stem cell therapies are still mostly theory. So what is going on? How can there be clinics, even chains of clinics run by companies, offering stem cell treatment for almost any disease you can think of — sports injuries, arthritis, autism, cerebral palsy, stroke, muscular dystrophy, A.L.S., cancer?

Being out of shape could be more harmful to health and longevity than most people expect, according to a new, long-term study of middle-aged men. The study finds that poor physical fitness may be second only to smoking as a risk factor for premature death.

It is not news that aerobic capacity can influence lifespan. Many past epidemiological studies have found that people with low physical fitness tend to be at high risk of premature death. Conversely, people with robust aerobic capacity are likely to have long lives.

But most of those studies followed people for about 10 to 20 years, which is a lengthy period of time for science but nowhere near most of our actual lifespans. Some of those studies also enrolled people who already were elderly or infirm, making it difficult to extrapolate the findings to younger, healthier people.

So for the new study, which was published this week in the European Journal of Preventive Cardiology, researchers from the University of Gothenburg in Sweden and other institutions turned to an impressively large and long-term database of information about Swedish men.

The data set, prosaically named the Study of Men Born in 1913, involved exactly that. In 1963, almost 1,000 healthy 50-year-old men in Gothenburg who had been born in 1913 agreed to be studied for the rest of their lives, in order to help scientists better understand lifetime risks for disease, especially heart disease.

Wednesday, July 27, 2016

PORTLAND, Me. — A woman in her 30s was sitting in a car in a parking lot here last month, shooting up heroin, when she overdosed. Even after the men she was with injected her with naloxone, the drug that reverses opioid overdoses, she remained unconscious. They called 911.

Firefighters arrived and administered oxygen to improve her breathing, but her skin had grown gray and her lips had turned blue. As she lay on the asphalt, the paramedics slipped a needle into her arm and injected another dose of naloxone.

In a moment, her eyes popped open. Her pupils were pinpricks. She was woozy and disoriented, but eventually got her bearings as paramedics put her on a stretcher and whisked her to a hospital.
Every day across the country, hundreds, if not thousands, of people who overdose on opioids are being brought back to life with naloxone. Hailed as a miracle drug by many, it carries no health risk; it cannot be abused and, if given mistakenly to someone who has not overdosed on opioids, does no harm. More likely, it saves a life.

As a virulent opioid epidemic continues to ravage the country, with 78 people in the United States dying of overdoses every day, naloxone's use has increasingly moved out of medical settings, where it has been available since the 1970s, and into the homes and hands of the general public.

But naloxone, also known by the brand name Narcan, has also had unintended consequences. Critics say that it gives drug users a safety net, allowing them to take more risks as they seek higher highs. Indeed, many users overdose more than once, some multiple times, and each time, naloxone brings them back.

Advocates argue that the drug gives people a chance to get into treatment and turn their lives around. And, they say, few addicts knowingly risk needing to be revived, since naloxone ruins their high and can make them violently ill.

Tuesday, July 26, 2016

She had already made it through one last night alone under the freeway bridge, through the vomiting and shakes of withdrawal, through cravings so intense she'd scraped a bathroom floor searching for leftover traces of heroin. It had now been 12 days since the last time Amanda Wendler used a drug of any kind, her longest stretch in years. "Clear-eyed and sober," read a report from one drug counselor, and so Amanda, 31, had moved back in with her mother to begin the stage of recovery she feared most.

"Is this everything I have?" she asked, standing with her mother in the garage of their two-bedroom condominium, taking inventory of her things. There were a few garbage bags filled with clothes. There was a banged-up dresser she had put into storage before moving into her first abandoned house.

"Where's my good makeup?" Amanda asked.

"Maybe you pawned it with the jewelry," said her mother, Libby Alexander.

"What about all of my shoes?"

"Oh, God. Are you serious?" Libby said. "Do you even know how many pairs of shoes you've lost or sold?"

Amanda lit a cigarette and sat in a plastic chair wedged between the cat food and the recycling bins in the garage, the only place where she was allowed to smoke. This was the ninth time she had managed to go at least a week without using. She had spent a full decade trying and failing to get clean, and a therapist had asked her once to make a list of her triggers for relapse. "Boredom, loneliness, anxiety, regret, shame, seeing how I haven't gone up at all in my life when the drugs aren't there," she had written.

She had no job, no high school diploma, no car and no money beyond what her mother gave her for Mountain Dew and cigarettes. A few days earlier, a dentist had pulled all 28 of her teeth, which had decayed from years of neglect. It had been a week since she'd seen her 9-year-old twin sons, who lived in a nearby suburb with their father, and lately the most frequent text messages coming into her phone were from a dealer hoping to lure her back with free samples: "Got testers," he had just written. "Get at me. They're going fast."

In the addicted America of 2016, there are so many ways to take measure of the pain, longing and despair that are said to be driving a historic opiate epidemic: Another 350 people starting on heroin every day, according to estimates from the Centers for Disease Control and Prevention; another 4,105 emergency-room visits; another 79 people dead. Drug overdoses are now the leading cause of injury-related death in the United States — worse than guns, car crashes or suicides. Heroin abuse has quadrupled in the past decade. Most addicts are introduced to heroin through prescription pain pills, and doctors now write more than 200 million opiate prescriptions each year.

But the fact that matters most for a chronic user is what it takes for just one addict to get clean. The relapse rate for heroin has been reported in various studies to be as high as 97 percent. The average active user dies of an overdose in about 10 years, and Amanda's opiate addiction was going on year 11.

Monday, July 25, 2016

For a baby born at 28 weeks—a full three months early—he was doing remarkably well, "feeding and growing" until he was big and strong enough to be cared for at home. As medical residents on the neonatal unit, we rarely saw this baby's family. But when we were able to reach his mother by telephone in between her work shifts, she was always loving, caring, appropriate, and eager for the day when her son, a perfect illustration of how modern medicine can impact even the tiniest baby's chance for a long and healthy life, would be ready to come home.

We rotated to other parts of the hospital, and this baby faded out of mind until we ran into the new resident caring for him and learned there was a Child Protective Services investigation underway. After a moment of confusion and bewilderment, our hearts sank as we understood what had happened: CPS and the medical team were concerned his mother—young, single, and working two full-time jobs in a town hours away from the hospital while supporting two other toddlers at home—simply could not pull together the resources to be present enough at the hospital to demonstrate her competence and commitment to caring for her baby.

After a few moments of collective frustration, anger, and most of all sadness for this family, we went back to work, shaken by yet another example of poor, disadvantaged parents being held to impossible standards. Cases like this are particularly painful for us because they stand in stark contrast to another situation of, we would argue, more serious parental neglect: Parents who deny their children the basic and essential medical care vaccinations provide.